Evolution of Echocardiographic Measures of Cardiac Disease From CKD to ESRD and Risk of All-Cause Mortality: Findings From the CRIC Study

Abstract

Rationale & objective: Abnormal cardiac structure and function are common in chronic kidney disease (CKD) and end-stage renal disease (ESRD) and linked with mortality and heart failure. We examined changes in echocardiographic measures during the transition from CKD to ESRD and their associations with post-ESRD mortality.

Study design: Prospective study.

Setting & participants: We studied 417 participants with CKD in the Chronic Renal Insufficiency Cohort (CRIC) who had research echocardiograms during CKD and ESRD.

Predictor: We measured change in left ventricular mass index, left ventricular ejection fraction (LVEF), diastolic relaxation (normal, mildly abnormal, and moderately/severely abnormal), left ventricular end-systolic (LVESV), end-diastolic (LVEDV) volume, and left atrial volume from CKD to ESRD.

Outcomes: All-cause mortality after dialysis therapy initiation.

Analytical approach: Cox proportional hazard models were used to test the association of change in each echocardiographic measure with postdialysis mortality.

Results: Over a mean of 2.9 years between pre- and postdialysis echocardiograms, there was worsening of mean LVEF (52.5% to 48.6%; P<0.001) and LVESV (18.6 to 20.2mL/m^2.7; P<0.001). During this time, there was improvement in left ventricular mass index (60.4 to 58.4g/m^2.7; P=0.005) and diastolic relaxation (11.11% to 4.94% with moderately/severely abnormal; P=0.02). Changes in left atrial volume (4.09 to 4.15mL/m²; P=0.08) or LVEDV (38.6 to 38.4mL/m^2.7; P=0.8) were not significant. Worsening from CKD to ESRD of LVEF (adjusted HR for every 1% decline in LVEF, 1.03; 95% CI, 1.00-1.06) and LVESV (adjusted HR for every 1mL/m^2.7 increase, 1.04; 95% CI, 1.02-1.07) were independently associated with greater risk for postdialysis mortality.

Limitations: Some missing or technically inadequate echocardiograms.

Conclusions: In a longitudinal study of patients with CKD who subsequently initiated dialysis therapy, LVEF and LVESV worsened and were significantly associated with greater risk for postdialysis mortality. There may be opportunities for intervention during this transition period to improve outcomes.

Keywords: CKD to ESRD transition; Kidney; all-cause mortality; cardiac disease; cardiovascular disease (CVD); dialysis; dialysis initiation; diastolic relaxation; echocardiogram; end-stage renal disease (ESRD); heart failure; left atrial volume; left ventricular ejection fraction (LVEF); left ventricular end-diastolic volume (LVEDV); left ventricular end-systolic volume (LVESV); left ventricular mass index (LVMI); subclinical CVD.